There is an urgent need to determine pathways to cardiovascular disease (CVD) prevention for under- represented racial/ethnic minorities with HIV and elevated cardiovascular risk. Such evidence will ultimately inform clinical care guidelines and health system interventions to improve health for health disparity populations with HIV. Thus, the long-term goal of this proposal is to generate evidence-based recommendations for the management of CVD risk in PLWH. The overall objectives of this application are to demonstrate the effect of cardiology referral on CVD health outcomes in a large racially/ethnically diverse cohort of people living with HIV (PLWH), and to generate qualitative and quantitative evidence to guide development of a future intervention. Our central hypothesis is that cardiology referral reduces incident CVD events in Blacks/African-Americans and other racial/ethnic minorities with HIV compared to non-referral. The rationale for our research is that, once it is known how these health disparity populations with HIV access cardiology referrals and the subsequent impact on CVD outcomes, an interventional can be appropriately designed to test new and innovative approaches to the management of co-morbidities for PLWH at elevated CVD risk. We plan to test our central hypothesis and thereby accomplish our overall objectives by pursuing the following three specific aims: (Aim 1) To measure the association between cardiology referral and CVD outcomes in under-represented racial/ethnic minorities with HIV, (Aim 2) To identify the individual- and health system-level factors that impact CVD outcomes for under-represented racial/ethnic minorities, and (Aim 3) To develop a qualitative framework for an intervention to improve CVD outcomes in PLWH. We will retrospectively analyze patient-level data from electronic health records from institutions in the U.S. Southeast ?HIV-belt? and ?Heart Attack belt?, using PCORnet?s Common Data Model. We will retrospectively identify cohorts of African- American and other under-represented racial/ethnic minorities and non-Hispanic white patients with HIV. Start date will be first clinical contact after January 1, 2010 to create a contemporary cohort with at least 5 years of longitudinal follow-up. The main independent variable is a clinic visit with a cardiologist, compared to not having such a visit, prior to first CVD event. Our primary outcome is myocardial infarction, hospitalization for heart failure, stroke, coronary heart disease, death or cardiovascular death after 5 years. Our scientific contribution is expected to be significant because we are addressing a dire health comorbidity for PLWH. Our group?s efforts are likely to contribute to greater understanding of how HIV-related CVD effects treatment outcomes among under-represented racial/ethnic minorities with HIV. As a consequence of the work proposed, we expect to identify the underlying pathways to ideal CVD care for under-represented racial/ethnic minorities with HIV. We anticipate results that lead to better integration and coordination of care and ultimately improve CVD health outcomes for health disparity populations with HIV.